World Congress addresses global health program integration

Experts in global development gathered in Washington over the weekend to discuss myriad topics, ranging from the global food crisis (11 million in Africa are at risk of going hungry with the current drought); to the tough fiscal environment (most notably the debt negotiations taking place on Capitol Hill); and taking advantage of opportunities in areas that continue to see record economic growth, like China (gross domestic product has grown at 9.9 percent for the past 30 years) and Africa (growing at five percent).

Robert Clay (right), deputy assistant administrator for global health at the U.S. Agency for International Development, and Ann Gavaghan, chief of staff at the Office of the Global AIDS Coordinator, participate in a panel discussion Friday at the SID World Congress.

“There have been spectacular successes at least in the last decade by taking a vertical approach to global health,” said session moderator Jim Kolbe, a former Member of the House of Representatives (R-AZ) and currently a member of the Global Health Council, citing HIV/AIDS and the provision of antiretroviral therapy, malaria, and the near eradication of polio as major achievements. But, he said, more recently there has been a call for taking an integrated approach to create sustainable health systems that provide for enduring health programs. This is in no small part driven by President Obama’s Global Health Initiative and its focus on maternal and child health (MCH), rather than specific diseases or conditions.

Robert Clay, deputy assistant administrator for global health at the U.S. Agency for International Development, had several words of wisdom from his experience working with the Zambian government. Economic hard times hit the country in the early 90s, Clay said, and the health sector moved forward with some innovative health reform ideas very quickly. U.S. aid (traditionally siloed, disease-specific responses) tried to integrate with Zambia’s integrated health program, a process that started in 1996. Although the benefits to this integration experiment have yet to be fleshed out, Clay had this advice for those pursuing integrated models:

There is no perfect model – the trick is to know your strengths and weaknesses and focus on those areas that are weak, minimizing how they can trip you up.

Moving toward an integrated approach requires dedicating a lot of time on coordinating the different technical staff, making sure they work together and have common goals.

Balanced funding.

Focus on results. Without results and clear indicators of success you can become vulnerable to funders saying, “We are giving you this money, what are you doing with it?”

Beef up training of staff in programmatic areas

This process takes time – creating an integrated, country-owned, sustainable response really means you are in it for the long haul.

“There is growing evidence that integration is cost-effective,” Clay said. “So even though there is no new money, we have to be effective with how we are using our existing resources. If you integrate these [program areas] together – HIV/AIDS, MCH, etc – you can save resources.”

When asked how we get attention paid to other health issues as we have seen to HIV/AIDS, Ann Gavaghan, chief of staff at the Office of the Global AIDS Coordinator who was trained as an HIV counselor, said the vertical disease programs benefit the health system across the board. For example, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program created safe blood systems for the purpose of reducing HIV transmission, but this system had an additional benefit on maternal mortality. “Safe blood is available for birthing mothers if they need it,” Gavaghan said, reducing the number of mothers that die during childbirth.

“I think we need to stop focusing on the disease and start focusing on the person.”

At a recent visit to a health clinic in Malawi, Gavaghan and her colleagues encountered no electricity, abandoned housing projects for nurses, a broken running water system, and a general frustration with the inability of the dedicated health care work force to offer integrated services to their clients.

“Every person that goes to that clinic – whether a woman going to deliver, someone seeking HIV services, a kid with malaria – we need to say, at the clinic level, this is what we need [to serve these people],” Gavaghan said. In order to do that, she said, clinics need to identify what services they can offer, what capital equipment exists and if it works, and where services need to go (e.g. getting services to rural areas and taking platforms that exist and building upon them by pooling funding).

It remains to be seen whether health services integration, in the absence of additional resources, will improve or undermine health outcomes for specific conditions including HIV infection.